1. Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.

2. DEFINITION
“Any pregnancy where the fertilised ovum
gets implanted & develops in a site other
than normal uterine cavity”.
It represents a serious hazard to a woman’s
health and reproductive potential, requiring
prompt recognition and early aggressive
intervention.

3. Is one in which fertilized ovum is implanted &
develops outside normal uterine cavity

4. IMPLANTATIONS SITES
EXTRAUTERINE UTERINE
-CERVICAL
TUBAL 95-96% OVARIAN ABDOMINAL (1:18,000)
(1:40,000) (1:10,000) -ANGULAR
-Ampulla 70% -CORNUAL
-Isthmus 12% -CAESAREAN
PRIMARY SECONDARY
-Infundibulum 11% SCAR (<1)
-Interstitial &
cornual 2% Intraperitoneal Extraperitoneal
Broad Ligament
(rare)

6. INCIDENCE
• Increased due to PID, use of IUCD, Tubal
surgeries, and Assisted reproductive
techniques (ART).
• Ranges from 1:25 to 1:250
• Average range is 1 in 100 normal
pregnancies.
• Late marriages and late child bearing ->
2%
• ART -> 5%
• Recurrence rate - 15% after 1st, 25% after
2 ectopics

7. ETIOLOGY:
 Any factor that causes delayed transport
of the fertilised ovum through the tube.
 Fallopian tube favours implantation in the
tubal mucosa itself thus giving rise to a
tubal ectopic pregnancy.
 These factors may be Congenital or
Acquired.

8. ETIOLOGY
 CONGENITAL
• Tubal Hypoplasia
• Tortuosity
• Congenital diverticuli
• Accessory ostia
• Partial stenosis
• Elongation
• Intamural polyp
• Entrap the ovum on its way.

9.  ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
Chlamydia trachomatis is most common
Contraceptive Faliure
CuT - 4%
Progestasart -17%
Minipills -4-10%
Norplant -30%

10. Tubal sterilization faliure -40%
Depends on sterilization technique and age of
the patient
Bipolar Cauterisation -65%
Unipolar Cautery -17%
Silicon rubber band -29%
Interval Salpingectomy -43%
Postpartum Salpingectomy -20%
Reversal of sterilisation
- Depends on method of sterilization, Site of
tubal occlusion, residual tubal length.
- Reanastomosis of cauterised tube -15%
- Reversal of Pomeroy’s - < 3%

11. Tubal reconstructive surgery (4-5 times)
Assisted Reproductive technique
- Ovulation induction, IVF-ET and GIFT (4-7%)
- Risk of heterotopic pregnancy(1%)
Previous Ectopic Pregnancy
- 7-15% chances of repeat ectopic pregnancy

12. Other Risk factors
 Age 35-45 yrs
 Previous induced abortion
 Previous pelvic surgeries
 Cigarette smoking
 DES Exposure in Utero
 Infertility
 Salpingitis Isthmica Nodosa
 Genital Tuberculosis
 Fundal Fibroid & Adenomyosis of tube
 Transperitoneal migration of ovum

13. Iffy hypothesis –
“Theory of reflux” menstural fluid throw the
fertilised ovum into the tube
Factors facilitating nidation of ovum in tube:
- Premature degeneration of zona pellucida
- Increased decidual reaction
- Tubal endometriosis

14. Evolution
 Tubal pregnancies rapidly invade the
mucosa, feeding from the tubal vessels,
which become enlarged and engorged. The
segment of the affected tube is distended
as the pregnancy grows. Possible
outcomes of such abnormal gestations are
as follows:

15.  The pregnancy is unable to survive owing
to its poor blood supply, thus resulting in a
tubal abortion and resorption, or it is
expelled from the fimbriated end into the
abdominal cavity.
 The pregnancy continues to grow until the
overdistended tube ruptures, with
resulting profuse intraperitoneal bleeding.
 Isthmic – 6-8 wks, Ampullary – 8-12wks,
Interstitial -4 months
 Abortion is common in ampullary
pregnancies,whereas rupture is in isthmic.

16.  In rare instances, a tubal pregnancy will
be expelled from the tube and seed onto
sites in the abdominal cavity (e.g. the
omentum, the small or large bowel, or the
parietal peritoneum), and gives rise to a
viable abdominal pregnancy.

18. Pictures showing
TUBAL ABORTION

19. CLINICAL APPROACH
 Dignosis can be done by history, detail examination
and judicious use of investigation.
 H/o past PID, tubal surgery,current contraceptive
measures should be asked
 Wide spectrum of clinical presentation from
asymtomatic pt to others with acute abdomen and in
shock.

20. ACUTE ECTOPIC PREGNANCY
 Classical triad is present in 50% of pt with
rupture ectopic.
- PAIN:- most constant feature in 95% pt
- variable in severity and nature
- AMENORRHOEA:- 60-80% of pt
- there may be delayed period or slight
spotting at the time of expected menses.
- VAGINAL BLEEDING: - scanty dark brown
 Feeling of nausea,vomiting,fainting attack, syncope
attack(10%) due to reflex vasomotor disturbance.

21.  O/E:- patient is restless in agony, looks blanched,
pale, sweating with cold clammy skin.
Features of shock, tachycardia, hypotension.
 P/A:- abdomen tense, tender mostly in lower
abdomen,shifting dullness, rigidity may be
present.
 P/S:- minimal bleeding may be present
 P/V:- uterus may be bulky, deviated to opposite
side, fornix is tender, excitation pain on
movement of cervix.
POD may be full, uterus floats as if in water.

22. CHRONIC ECTOPIC PREGNANCY
 It can be diagnosed by high clinical suspicion.
 Patient had previous attack of acute pain from
which she has recovered.
 She may have amenorrhoea, vaginal bleeding
with dull pain in abdomen,and with bladder and
bowel complaints like dysuria,frequency or
retention of urine, rectal tenesmus.

23.  O/E:- patient look ill, varying degree of pallor,
slightly raised temperature. Features of shock
are absent.
 P/A:- Tenderness and muscle guard on the lower
abdomen.
A mass may be felt, irregular and tender.
 P/V:- Vaginal mucosa pale, uterus may be normal
in size or bulky, ill defined boggy tender
mass may be felt in one of the fornix.

24. UNRUPTURED ECTOPIC
 High degree of suspicion & ectopic conscious
clinician can diagnose.
 Diagnosed accidentally in Laparoscopy or
Laparotomy
C/F – delayed period, spotting with discomfort in
lower abdomen.
P/A – tenderness in lower abdomen
P/V – should be done gently
uterus is normal size, firm
small tender mass may be felt in the fornix

27. DIAGNOSIS
“Pregnancy in the fallopian tube is a black
cat on a dark night. It may make its
presence felt in subtle ways and leap at you
or it may slip past unobserved. Although it is
difficult to distinguish from cats of other
colours in darkness, illumination clearly
identifies it.”
--Mc. Fadyen - 1981

28. DIAGNOSIS
 In recent years, inspite of an increase in the
incidence of ectopic pregnancy there has been a
fall in the case fatality rate.
 This is due to the widespread introduction of
diagnostic tests and an increased awareness of
the serious nature of this disease.
 This has resulted in early diagnosis and effective
treatment.
 Now the rate of tubal rupture is as low as 20%.

29. DIAGNOSIS
 Patient with acute ectopic can be diagnosed clinically.
 Blood should be drawn for Hb gm%, blood grouping
and cross matching, DC and TWBC, BT, CT.
 Should be catheterized to know urine output.
Bed side test:-
1. Urine pregnancy test:- positive in 95% cases.
ELISA is sensitive to 10-50 mlU/ml of β hCG and
can be detected on 24th day after LMP.

30. 2. Culdocentesis:- (70-90%)
- Can be done with 16-18 G lumbar
puncture needle through posterior fornix
into POD.
- Positive tap is 0.5ml of non clotting blood.
 Other Investigations:-
1. Ultra Sonography-
a) Transvaginal Sonography (TVS):
- Is more sensitive
- It detect intrauterine gestational sac at
4-5wks and at S-β hCG level as low as 1500

31.  Endometrial cavity
-A trilaminar endometial pattern seen
-pseudogestational sac
-decidual cyst may be seen
PSEUDOSAC – All pregnancies induce an endometrial
decidual reaction, and sloughing of the decidua can
create an intracavitary fluid collection called a
pseudosac
Early gestational sac Pseudosac
location below the midline echo along the
burried into endometium cavity line b/w
endometrial
layers
shape usually round may
change,oviod
borders double ring single layer

32. DECIDUAL CYST
It is identified as an anechoic area lying with in the
endometrium but remote from the canal and often at
the endometrial-myometrial border.
 Adenxa
- 15-30% an extrauterine yolk sac or embryo seen
in fallopian tubes confirms tubal pregnancy.
- A halo or tubal ring surrounded by a thin
hypoechoic area caused by subserosal edema can be
seen.
 Rectouterine cul-de-sac
Free peritonial fluid with an adnexal mass
suggestive of ectopic pregnancy

33. b) Color Doppler Sonography(TV-CDS):
- Improve the accuracy.
-Identify the placental shape (ring-
of-fire pattern) and blood flow
outside the uterine cavity.
c) Transabdominal Sonography:
- can identify gestational sac at 5-6 wks
- S-β hCG level at which intrauterine gestational
sac is seen by TAS is 1800 IU/L.

34. USG PICTURE
1.‘Bagel’ sign – Hyperechoic ring around gestational
sac in adnexal region
2. ‘Blob’ sign – Seen as small inconglomerate mass
next to ovary with no evidence of sac or
embryo.
3. Adnexal sac with fetal pole and cardiac activity is
most specific.
4. Corpus luteum is useful guide when looking for
EP as present in 85% cases in Ipsilateral ovary.

35. Hyperechoic ring around
gestational sac in adnexal region

36. Ring sign — a hyperechoic ring around an
extrauterine gestational sac.

37. 2. β-HCG Assay-
a) Single β-HCG: little value
b) Serial β-HCG: is required when result of
initial USG is confusing.
- When hCG level < 2000 IU/L doubling time
help to predict viable Vs nonviable pregnancy.
-Rise of β-HCG <66% in 48 hrs indicate
ectopic pregnancy or nonviable intrauterine
pregnancy .
Biochemical pregnancy is applied to those
women who have two β-HCG values >10 IU/L

38. 3. Serum Progesterone –
- level >25 ngm/ml is suggestive of normal
intrauterine pregnancy.
- level <15 ngm/ml is suggestive of ectopic
pregnancy.
- level <5 ngm/ml indicates nonviable
pregnancy, irrespective of its location.
4. Diagnostic Laparoscopy (Gold standard)–
- Can be done only when patient is
haemodynamically stable.
-It confirms the diagnosis and removal of
ectopic mass can be done at the same time.

39. 5. Dilatation & Curettage –
- Is recommended in suspected case of
incomplete abortion vs ectopic pregnancy.
- Identification of decidua without chorionic
villi is suggestive of extra uterine pregnancy.
- “Arias-Stella” endometrial reaction is
suggestive but not diagnostic of ectopic
pregnancy.
6. Other hormonal Tests –
- Placenta protein (PP14) decrease in EP
- PAPPA (Pregnancy Associated Plasma Protein A),
PAPPC (schwangerchaft protein 1) has low value
in EP
- CA-125, Maternal serum creatine kinase,
Maternal serum AFP elevated in ectopic
pregnancy.

40. SUSPECTED ECTOPIC PREGNANCY
Urine Pregnancy test positive
Transvaginal USG
IU sac No IU sac
Quantitative S-hCG
+ S progesterone
< 66% rise in 48 hr or >66% rise in 48 hr or
S progesterone < 5-10 ng/ml S progesterone > 5-10 ng/ml
D&C Repeat S-hCG in 48 hrs
till USG discrimination zone
Villi present Villi absent
Incomplete Laparoscopy No sac IU sac
abortion
Continue to monitor

41. DIFFERENTIAL DIAGNOSIS
D/D of Acute Ectopic
1. Rupture corpus luteum of pregnancy
2. Rupture of chocolate cyst
3. Twisted ovarian cyst
4. Torsion / degeneration of pedunculated fibroid
5. Incomplete abortion
6. Acute Appendicitis
7. Perforated peptic ulcer
8. Renal colic
9. Splenic rupture

42. D/D OF CHRONIC (SUB ACUTE) ECTOPIC
1. Pelvic abscess
2. Pyosalpinx
3. Subserous uterine fibroid
4. Salpingintis
5. Retroverted gravid uterus
6. Appendicular lump

43. MANAGEMENT
Expectant Medical Surgical
management management management
Local Systemic Radical Conservative
(USG or Laparoscopic) Salpingectomy
salpingocentesis
Methotrexate
-Salpingostomy
- Methotrexate
- Potassium chloride
-Salpingotomy
- Prostagladin(PGF2α)
- Hypersmolar glucose
- Segmental
- Actinomycin D
resection
- Mifepristone
-Milking or fimbrial
expression

44. MANAGEMENT OF RUPTURED ECTOPIC
PRINCIPLE: Resuscitation and Laparotomy
ANTI SHOCK TREATEMENT:
- IV line made patent, crystalloid is started
- Blood sample for Hb, blood grouping & cross matching,
BT, CT
- Folley’s catheterization done
- Colloids for volume replacement
LAPAROTOMY:
Principle is ‘Quick in and Quick out’
- Rapid exploration of abdominal cavity is done
- Salpingectomy is the definitive surgery (sent for HP study)
- Blood transfusion to be given
- Autotransfusion only when donated blood not available.

46. MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
OPTIONS: -
 SURGICAL-
 SURGICALLY ADMINISTERED
MEDICAL (SAM) TREATMENT
 MEDICAL TREATMENT
 EXPECTANT MANAGEMENT

47. EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA (Ylostalo et al , 1993)- :
1. Tubal ectopic pregnancies only
2. Haemodynamically stable
3. Haemoperitoneum < 50ml
4. Adnexal mass of < 3.5 cm without heart beat.
5. Initial β HCG <1000 IU/L and falling in titre
SUCCESS RATE - Upto 60%
PROTOCOL:
- Hospitalization with strict monitoring of clinical symptom
- Daily Hb estimation
- Serum β HCG monitoring 3-4 days until it is <10 IU/L

48. EXPECTANT MANAGEMENT
 Spontaneous resolution occurs in 72%,while 28%
will need laparoscopic salpingostomy
 In spontaneous resolution, it may take 4-67 days
(mean 20 days) for the serum HCG to return to
non pregnant level.
 The percentage fall in serum HCG by day 7 is a
better indicator than the percentage fall by day 2.
 Warning: - Tubal pregnancies have been known
to rupture even when Serum HCG levels are low.

49. MEDICAL MANAGEMENT
Surgery is the mainstay of T/t worldwide
Medical M/m may be tried in selected cases
CANDIDATES FOR METHOTREXATE (MTX)
 Unruptured sac < 3.5cm without cardiac activity
 S-hCG < 10,000 IU/L
 Persistant Ectopic after conservative surgery
PHYSICIAN CHECK LIST
 CBC, LFT, RFT, S-hCG
 Transvaginal USG within 48 hrs
 Obtain informed consent
 Anti-D Ig if pt is Rh negative
 Follow up on day1, 4 and 7.

50. MEDICAL MANAGEMENT
METHOTREXATE:
 It can be used as oral,intramuscular ,intravenous usually
along with folinic acid.
 Resolution of tubal pregnancy by systemic administration of
Methotrexate was first described by Tanaka et al (1982)
 Mostly used for early resolution of placental tissue in
abdominal pregnancy.Can also be used for tubal
pregnancy.
 Mechanism of action-Methotrexate is a folic acid
antagonist that inactivates the enzyme dihydrofolate
reductase.Interferes with the DNA synthesis by inhibiting
the synthesis of pyrimidines leading to trophoblastic cell
death. Auto enzymes and maternal tissues then absorb the

52. Contd……
 Advantages –
• Minimal Hospitalisation.Usually outdoor
treatment
• Quick recovery
• 90% success if cases are properly selected
 Disadvantages-
• Side effects like GI & Skin
• Monitoring is essential- Total blood count, LFT
& serum HCG once weekly till it becomes
negative

53. SURGICALLY ADMINISTERED MEDICAL Tt
(SAM)
 Aim- trophoblastic destruction without systemic
side effects
 Technique- Injection of trophotoxic substance
into the ectopic pregnancy sac or into the
affected tube by-
• Laparoscopy or
• Ultrasonographically guided
 Transabdominal (Porreco, 1992)
 Transvaginal (Feichtingar, 1987)
• With Falloposcopic control (Kiss, 1993)

54. SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
Trophotoxic substances used-
Methtrexate (Pansky, 1989)
Potassium Chloride (Robertson, 1987)
Mifiprostone (RU 486)
PGF2α (Limblom, 1987)
Hyper osmolar glucose solution
Actinomycin D
Advantage of local MTX :
- Increase tissue concentration at local site
- Decrease systemic side effects
- Decrease hospitalization
- Greater preservation of fertility
Follow up: - Serum β HCG twice weekly till < 10 IU/L
- TVS weekly for 4-6 weeks
- HCG after 6 months for tubal patency

55. INSTRUCTION TO THE PATIENTS
 If T/t on outpatient basis rapid transportation should
be available
 Refrain from alcohol, sunlight, multivitamins with
folic acid, and sexual intercourse until S-hCG is
negative.
 Report immediately when vaginal bleeding,
abdominal pain, dizziness, syncope (mild pain is
common called separation pain or resolution pain)
 Failure of medical therapy require retreatment
 Chance of tubal rupture in 5-10 % require
emergency Laparotomy.

56. SURGICAL MANAGEMENT OF ECTOPIC
Conservative Surgery
Can be done Laparoscopically or by microsurgical laparotomy
INDICATION:
- Patient desires future fertility
- Contralateral tube is damaged or surgically removed
previously
CHOICE OF TECHNIQUE: depends on
- Location and size of gestational sac
- Condition of tubes
- Accessibility

57. VARIOUS CONSERVATIVE SURGERIES
1.Linear Salpingostomy:
- Indicated in unruptured ectopic <2cm in ampullary region.
- Linear incision given on antimesentric border over the site
and product removed by fingers, scalpel handle or gentle
suction and irrigation.
- Incision line kept open (heals by secondary intention)
2. Linear Salpingotomy :
- Incision line is closed in two layers with 7-0 interrupted
vicryl sutures.
3. Segmental Resection & Anastomosis:
- Indicated in unruptured isthmic pregnancy
- End to end anastomosis is done immediately or at later
date

58. 4. Milking or fimbrial Expression:
- This is ideal in distal ampullary or infundibular pregnancy.
- It has got increased risk of persistent ectopic pregnancy.
ADVANTAGES OF LAPAROSCOPY
- It helps in diagnosis, evaluation, and treatment .
- Diagnose other causes of infertility.
- Decreased hospitalization, operative time, recovery period,
analgesic requirement.
Follow up after conservative surgery
- With weekly Serum β HCG titre till it is negative.
- If titre increases methotrexate can be given.

59. DEBATABLE ISSUES
? Salpingectomy Vs Salpingostomy
? Laparotomy Vs Laparoscopy
? Reproductive outcome
? Risk of Recurrent Ectopic

60. SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY
 All tubal pregnancies can be treated by partial or
total Salpingectomy
 Salpingostomy / Salpingotomy is only indicated
when:
1. The patient desires to conserve her fertility
2. Patient is haemodinamically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 5Cm. In size
5. Contralateral tube is absent or damaged

61. CONTD……
 The choice of surgical treatment does not influence the
post treatment fertility, but prior history of infertility is
associated with a marked reduction in fertility after
treatment.
 Making the choice – Chapron et al (1993) have
described a scoring system, based on the patient’s
previous gynaecological history and the appearance of
the pelvic organs, to decide between salpingostomy /
salpingotomy and salpingectomy.

62. Fertility reducing factor Score
• Antecedent one Ectopic pregnancy 2
• Antecedent each further
Ectopic pregnancy 1
• Antecedent Adhesiolysis 1
• Antecedent Tubal micro surgery 2
• Antecedent Salpingitis 1
• Solitary tube 2
• Homolateral Adhesions 1
• Contralateral Adhesions 1
• The rationale behind the scoring system is to decide the risk of
recurrent ectopic pregnancy.
• Conservative surgery is indicated with a score of 1-4 only,
while radical treatment is to be performed if the score is 5 or
more.

63. Laparotomy Vs Laparoscopy
- Laparoscopy is reserved for pt who are
hemodynamically stable.
- Ruptured Ectopic does not necessarily require
Laparotomy, but if large clots are present
Laparotomy should be considered.
Reproductive outcome
Is similar in pt treated with either Laparoscopy or
Laparotomy.
Identical rates of 40% of IUP, around 12% risk of
recurrent pregnancy with either radical or
conservative pregnancy.

64. LAPAROSCOPIC SALPINGECTOMY
It is carried out by laparoscopic scissors & diathermy or Endo-loop.
After passing a loop of No.1 catgut over the ectopic pregnancy the
stitch is tightened and then the tubal pregnancy is cut distal to
the loop stitch.
The excised tissue is removed by piece meal or in tissue removal bag
LAPAROSCOPIC SALPINGOTOMY
 To reduce blood loss, first 10-40 IU of vasopressin diluted in10 ml
of normal saline is injected into the mesosalpinx.
 Then the tube is opened through an antimesenteric longitudinal
incision over the tubal pregnancy by a
– Co2 laser (Paulson, 1992)
– Argon laser (Keckstein et al; 1992)
– Laparoscopic scissors and ablating the bleeding points with
bipolar diathermy.
– Fine diathermy knife (Lundorff, 1992)
 The tubal pregnancy is then evacuated by suction irrigation.

65. PERSISTENT ECTOPIC PREGNANACY
 This is a complication of salpingotomy / salpingostomy
when residual trophoblast continues to survive because of
incomplete evacuation of the ectopic pregnancy.
 Diagnosis is made because of a raised postoperative β HCG
 If untreated, can cause life threatening hemorrhage
Risk Factor: (seifer 1997)
1. Early ectopic pregnancy (< 6 wks amenorrhoea)
2. Smaller size < 2 cm (Incomplete removal)
3. Preoperative high serum β HCG (> 3,000 IU/L) and
postoperative Day1 titre is < 50% of preoperative level, is
predictor of persistent EP.
4. Implantation medial to the salpingostomy site.
surgery
Medical
Treatment
(selected Asymptomatic pt)
Total or partial MTX + Leukovorin
salpingectomy

66. OVARIAN ECTOPIC PREGNANCY
Incidence: 1:40,000
Risk factor: - IUCD
- Endometriosis on surface of ovary
Course:
C/F are same as tubal pregnancy
ruptures within 2-3 wks
Diagnosis: On Laparotomy
Spiegelberg’s Criteria
1. Ipsilateral tube is intact and separate from sac
2. Sac occupies the position of the ovary
3. Connected to uterus by ovarian ligament
4. Ovarian tissue found on its wall on HP study
Ruptured M/M Unruptured
Laparotomy Ovarian wedge resection
Ovarian Cystectomy
Oophorectomy

67. ABDOMINAL PREGNANCY
Incidence: Rarest
MMR : 7-8 times > tubal ectopic
90 times > Intrauterine pregnancy
H/O : - Irregular bleeding, spotting
- Nausea, vomiting, flatulence, constipation,
diarrhoea, abdominal pain.
- Fetal movement may be painful and high in
the abdomen
O/E : - Abnormal fetal position, easy in palpating
fetal parts.
- uterus palpated separate from sac
- no uterine contraction after oxytocin
infusion

68. Diagnosis: Confirmed by USG,
CT scan, MRI, Radiography
TYPE
Primary Secondary
Studiford’s criteria
Conceptus escapes out
. Both tubes and ovaries normal through a rent from
primary site
. Absence of Uteroperitonal fistula
. Pregnancy related to Peritoneal
Intraperitoneal Extraperitoneal
surface & young enough to rule
Broad ligament
out possibility of secondary
implantation

69. FATE OF SECONDARY ABDOMINAL PREGNANCY :
1. Death of ovum – complete absorption
2. Placental separation – massive intraperitoneal
haemorrhage
3. Infection – fistulous communication with intestine,
bladder, vagina, or umbilicus
4. Fetus dies (majority) – mummification, adipocere
formation, or calcified to lithopaedion
5. Rarely – continue to term (malformation)
M/M:
- Urgent Laparatomy irrespective of period of gestation
- Ideal to remove entire sac fetus, placenta, membrane
- Placenta may be left if attached to vital organs, get
absorbed by aseptic autolysis

70. CERVICAL PREGNANCY
Implantation occurs in cervical canal at or below internal
Os.
Incidence: 1 in 18,000
RISK FACTORS :
- Previous induced abortion
- Previous caesarean delivery
- Asherman’s syndrome
- IVF
- DES exposure
- Leiomyoma

71. Diagnosis:
CLINICAL CRITERIA: Paulman & McEllin
1. Uterine bleeding, no cramping, following
amenorrhoea
2. Cervix distended,thin walled,soft consistency
3. Enlarged uterine fundus may be palpated.
4. Internal Os is closed
5. External Os is partially opened
USG CRITERIA: American Journal of O&G
1. Echo-free uterine cavity/ pseudo-gestational
sac
2. Decidual reaction
3. Hourglass uterus with ballooned cervical canal
4. Gestational sac in endocervix
5. Closed internal Os
6. Placental tissue in Cx canal

72. HISTOPATHOLOGIC CRITERIA: Rubin’s
1. Cervical glands present opposite to placenta
2. Placental attachment to the cervix must be
below the entrance of uterine vessels .
3. Fetal element absent from corpus uteri.
D/d :
- Carcinoma Cx
- Cervical submucous fibroid
- Trophoblastic tumour
- Placenta previa

73. MANAGEMENT
Surgical Medical
Mainstay therapy in past Recently proposed
Single or Combination
Conservative
Radical OR
surgery D&C Adjunct to surgery
(risk of torrential bleeding) - Methotrexate
Hysterectomy - Cerclage Bernstein ≈ Mc Donald’s - Actinomycin
Wharton ≈ Shirodkar’s
-Transvaginal ligation of Cx branch of - KCl
uterine artery
- Angiographic uterine A embolisation - Etoposide
- Intracervical vasopressin inj
- Foley’s catheter as tamponade

74. CORNUAL PREGNANCY
SITE: Implantation occurs in rudimentary horn of Bicornuate
uterus
COURSE :Rupture of horn occurs by
12-20 wks
D/D :
1. Interstitial tubal pregnancy
2. Painful leiomyoma along with
pregnancy
3. Ovarian tumor with pregnancy
4. Asymmetrical enlargement of uterus.
Implantation into cornu of normal uterus is sometime
called Angular pregnancy .
TREATEMENT:
- Affected cornu with pregnancy is removed
- Hysterectomy
- Hysteroscopically guided suction curettage if

75. HETEROTYPIC PREGNANCY
Co-existing intrauterine and extra uterine pregnancies
Incidence: 1 : 30,000
With ART – 1:7000
With ovulation induction – 1:900
More likely:
a) Ass. reproductive technique
b) Rising HCG titre after D & C
c) More than 1 corpus luteum at laparotomy
M/M :
Depends on the site. Ectopic site may be removed
with continuation of IU pregnancy
(Rh Immunoglobulin: dose of 50 μ gm is sufficient to
prevent sensitization.)

76. INTERSTITAL PREGNANCY (2%)
It ruptures late at 3-4 months gestation.
Fatal rupture – severe bleeding as both uterine &
ovarian artery supply.
Early & Unruptured – Local or IM MTX with followup
Cornual resection by Laparotomy may be done.
There is high risk of uterine rupture in
subsequent pregnancy.
Rupture – Hysterectomy is indicated

77. CAESAREAN SCAR ECTOPIC PREGNANCY
 Recently reported
 USG slows on empty uterine cavity and gestational
sac attached low to the lower segment caesarean
scar.
C/F : similar to threatened or inevitable abortion
Diagnosis : Doppler imaging confirms
T/t : Methotrexate injection
Hysterectomy in a multiparous women.
In young pt resection & suturing of scar may be
done (high risk of rupture).

78. OTHER RARE TYPES
1. Multiple Ectopic pregnancy
2. Pregnancy after hysterectomy
3. Primary splenic pregnancy
4. Primary hepatic pregnancy
5. Rectroperitoneal pregnancy
6. Diaphragmatic pregnancy
MORTALITY : In general population is 10-15% mainly
due to haemorrhage.

79. SUMMARY - KEY POINTS
 Incidence of ectopic pregnancy is rising while maternal
mortality from it is falling.
 Ectopic pregnancy can be diagnosed early (before it ruptures)
with recent advances in Immunoassay to detect S-hCG , high
resolution USG, and dignostic Laparoscopy.
 There has been shift in the M/m from ablative surgery to
conservative fertility preserving therapy
 Laparotomy should be done when in doubt
 The choice today is Laparoscopic treatment of unruptured
ectopic pregnancy.
 Careful monitoring and proper counselling of patients is
mandatory.